During an assessment of the cranial nerves, the nurse finds the following: Asymmetry when the client frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and an escape of air from the right side when the client puffs their cheeks. This would indicate the dysfunction of which of the cranial nerves?
Motor component of IV (Trochlear)
Motor and sensory components of XI (Accessory)
Motor component of VII (Facial)
Motor component of X (Vagus) and sensory component of XII (Hypoglossal)
The Correct Answer is C
A) Motor component of IV (Trochlear): The trochlear nerve primarily controls the superior oblique muscle of the eye, which is responsible for downward and lateral eye movements. The findings described do not relate to eye movement and therefore do not indicate dysfunction of this nerve.
B) Motor and sensory components of XI (Accessory): The accessory nerve innervates the sternocleidomastoid and trapezius muscles, primarily affecting head rotation and shoulder elevation. The symptoms noted in the assessment do not pertain to these muscle functions, so this option is not correct.
C) Motor component of VII (Facial): The signs of asymmetry in frowning, uneven eyebrow lifting, sagging eyelids, and air escaping when puffing the cheeks are characteristic of dysfunction in the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, and impairment would lead to the described asymmetrical movements.
D) Motor component of X (Vagus) and sensory component of XII (Hypoglossal): The vagus nerve affects autonomic functions and some swallowing muscles, while the hypoglossal nerve controls tongue movements. Neither nerve is primarily responsible for the facial expressions described in the assessment findings, making this option incorrect.
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Correct Answer is A
Explanation
A) Idiopathic neuropathy has no known cause: This statement is accurate, as idiopathic neuropathy refers to nerve damage for which no specific cause can be identified despite thorough investigation. The term "idiopathic" literally means "of unknown origin," indicating that the underlying mechanism remains unclear.
B) Idiopathic neuropathy is hereditary in nature: While some neuropathies can be hereditary, idiopathic neuropathy itself is not classified as hereditary since it lacks a defined genetic cause. Hereditary neuropathies are specific types that have a genetic basis.
C) Idiopathic neuropathy is caused by nutritional deficits: Nutritional deficits can lead to various types of neuropathy, but idiopathic neuropathy specifically is characterized by the absence of a known cause. Therefore, attributing it to nutritional deficits would be incorrect.
D) Idiopathic neuropathy is caused by disease or illness: While certain diseases can cause neuropathy, the key characteristic of idiopathic neuropathy is that no specific disease or illness has been identified as the cause. This differentiates it from other neuropathies that are secondary to identifiable conditions.
Correct Answer is A
Explanation
A) "What can we do to accommodate your needs during your stay here?" This response is the most appropriate as it demonstrates cultural sensitivity and respect for the client’s religious practices. It opens the door for a collaborative discussion about how the healthcare team can support the client’s fasting while ensuring that his health needs are met during hospitalization.
B) "I will let your healthcare provider know that you need to be discharged." While it is important to communicate the client’s needs to the healthcare provider, suggesting discharge may not be a feasible solution. It does not address the complexities of fasting during hospitalization and could imply that the client’s faith is a burden rather than a respected aspect of their care.
C) "Fasting may be harmful to your body during your illness." While it is crucial to ensure the client’s health is not compromised, this response could come off as dismissive of the client’s beliefs. Instead of expressing concern, it could be more beneficial to explore how fasting can be managed within the context of their medical care.
D) "You must eat a high protein diet during times of illness." This response does not take into account the client’s religious beliefs and fails to respect the significance of fasting in the Muslim faith. While dietary considerations are important, this approach disregards the client’s right to practice their faith and may come across as prescriptive rather than collaborative.